Harmonizing Nursing Education in Europe: Disparities, System Challenges, and Implications for Bulgaria

1. Introduction

Over the last two decades, nursing education in Europe has undergone a significant transformation through major reform initiatives, in particular the Bologna Declaration and the European Union (EU) Directives on the Regulated Professions. These reforms aimed to create a single European Higher Education Area (EHEA) and to establish common standards for nursing education [1]. However, emerging literature suggests that harmonisation has been more procedural than outcome-oriented, with persistent gaps in competency acquisition and workforce readiness [33]. Despite these harmonisation efforts, significant challenges remain in achieving consistent educational standards, curricula alignment and professional mobility across European countries [2]. The scale of these challenges is particularly evident in countries such as Bulgaria, which face additional complexities related to post-socialist transition, health system reforms and alignment with EU standards. Understanding these challenges and identifying opportunities for improvement require exploring both the wider European context and specific national circumstances.

The Bologna Process is the most significant reform initiative with an impact on nursing education in Europe, aiming to create coherent, compatible and competitive higher education systems [3]. This process has successfully moved the education of healthcare professionals from vocational training to higher education institutions in most European countries, most of which now offer undergraduate programmes [1]. The European Federation of Nurses’ Associations (EFN) Competency Framework has provided an additional structure to harmonise nursing competencies across member states [2]. On the other hand, many studies have revealed significant differences in European Credit Transfer System (ECTS) requirements ranging from 180 to 240 credits, clinical practice hours, and curriculum structures [2,4]. Northern European countries, despite their similarities, show an apparent lack of uniformity in medical education guidelines and structures [2]. These differences create challenges for professional mobility and raise questions about the adequacy of current EU frameworks for modern medical competencies [2]. In addition, rapid technological advancements and the integration of digital health systems require continuous updates of competency frameworks, which many national systems struggle to implement effectively [34]. European medical education is increasingly adopting competency-based curriculum approaches, emphasising the development of specific knowledge, skills and attitudes required for professional practice [1,5]. A multi-phase Delphi study involving six European countries identified 24 core evidence-based practice competencies [5]. These competencies encompass affective and cognitive conditions, providing a framework for curriculum development in different educational contexts [5]. Work is also underway towards unification on clinical competencies for nurses. EU directives stipulate that 50% of the curriculum should be devoted to laboratory and clinical practice in specialized hospital units [4]. However, compliance with these requirements varies considerably between countries. Some countries struggle to meet these standards due to insufficient clinical training opportunities, inadequate supervision or limited resources [4].

A study in 10 European countries showed that graduating nursing students rated their competence as “good”, with significant differences between countries, with Iceland presenting the highest levels of self-rated competence, while Lithuania—the lowest [6]. Factors associated with higher competence included older age, work experience in healthcare, satisfaction with educational programs, and academic excellence [6]. A large-scale systematic review examined the reasons for leaving nursing worldwide, categorizing four factors: policy and planning barriers, admission and training barriers, factors causing staff turnover, and factors related to patient health [7]. In general, globalisation and the free labour market created within the European space are a prerequisite for constant migration processes that lead to advantages for some countries and losses for others [8].

Another factor playing a role in nursing education is the strong feminization of the profession based on traditions and stereotypes. A methodological historical study notes the conflict between the Christian values on which the profession was founded and the development of nursing science, and similar dilemmas persist in contemporary education [9].

Specific challenges to nursing education in Bulgaria encompass several key factors. First and foremost, it is the national healthcare context. The healthcare system in Bulgaria has undergone continuous transition for more than two decades, developing under difficult economic, social and political circumstances [10]. The system suffers from extremely low nurse staffing levels, which creates a context that predisposes to difficult organizational and ethical conflicts [10]. Compared to other countries, Bulgaria has a particularly high relative number of human and dental doctors, but the relative number of nurses remains well below the EU average [11]. As with healthcare, Bulgarian higher education faces significant challenges in meeting the requirements of EU directives. Instability and inadequate funding of the healthcare system affect educational institutions, especially in terms of clinical practice opportunities and resource allocation [11]. This is further compounded by limited investment in academic–clinical partnerships, which are increasingly recognised as essential for high-quality nursing education in Europe [33]. Regional imbalances in the distribution of the healthcare workforce exacerbate these challenges, with significant disparities between urban and rural areas [12]. In addition to internal urbanization, the last 30 years have seen an intensified emigration process. Bulgaria is experiencing increased occupational mobility of healthcare workers, with many nurses emigrating to other EU countries [11,12]. The average age of first-year nursing students is remarkably high (30 years), indicating difficulties in attracting younger candidates to the profession [13]. The latter is due to a number of factors and challenges facing the nursing profession: small size of the profession, large number of inpatient and outpatient facilities, unsatisfactory working conditions, lack of autonomy, moral and ethical inconsistencies with the previous generation, etc. According to a study by the University of Rousse, low pay and lack of respect for the profession are the main factors discouraging future students in Bulgaria from choosing the specialty of nursing [14].

2. Materials and Methods

The review was structured using keywords and Boolean operators. In addition, algorithms were considered to work according to the Arksey and O’Malley protocol [15] and PRISMA ScR (Preferred Information Elements for Systematic Reviews and Meta Analyses for Scoping Reviews) [16].

The review aimed to address the following research question:

What is the current state of nursing education in Europe, and what evidence-based perspectives can be identified for improving the Bulgarian education system?

Given the exploratory nature of the study, a structured approach analogous to the PICO model was adapted, focusing on:

Population: nursing students and nursing education systems in Europe;

Concept: organisation, structure, and competencies in nursing education;

Context: European Higher Education Area and national systems, with emphasis on Bulgaria.

Search Strategy andData Sources

A preliminary exploratory search informed the selection of three databases: PubMed (Medline), Scopus, and Google Scholar. These were chosen to ensure broad coverage of medical, educational, and interdisciplinary literature. The search strategy combined keywords and Boolean operators (e.g., “nursing education AND European framework”), and was applied consistently across databases (Table 1).

The search was conducted in December 2025. No librarian was formally involved; however, the search strategy was iteratively refined by the authors to improve sensitivity and relevance.

Inclusion criteria were: publications in English or Spanish; studies published between 2010 and 2025; studies addressing nursing education in a European context;

all study designs (quantitative, qualitative, and reviews).

Exclusion criteria included: publications in other languages; studies published before 2010; studies not directly relevant to the research objective.

Study Selection Process

The selection process was conducted in two stages. First, titles and abstracts were screened to remove duplicates and irrelevant records. Second, full-text articles were assessed for eligibility. Both authors independently reviewed the studies, and any discrepancies were resolved through discussion and consensus.

Data Extraction and Synthesis

Data were extracted using a predefined framework, including: database source, authors, year, country, study design, and key findings.

A qualitative thematic analysis was applied. Initially, a deductive approach was used to group findings into broad categories aligned with the research objectives. This was followed by an inductive phase to identify emerging themes and recommendations relevant to the Bulgarian context.

Search Strategy and Study Selection Process

The review was conducted following the five stages of the Arksey and O’Malley framework [15]:

Stage 1: Identification of the research question—the study aimed to examine the current state of nursing education in Europe and identify evidence-based perspectives for improving the Bulgarian education system.

Stage 2: Identification of relevant studies—three databases (PubMed, Scopus, and Google Scholar) were searched using predefined keywords and Boolean operators (Table 1).

Stage 3: Study selection—a two-stage screening process (title/abstract followed by full-text review) was applied according to PRISMA-ScR guidelines [16]. The study selection process is illustrated in Figure 1 (PRISMA flow chart), which presents the number of records identified, screened, excluded, and included at each stage of the review. Initially, 1,492 records were identified. After removal of duplicates and irrelevant studies, titles and abstracts were screened, followed by full-text assessment for eligibility.

Stage 4: Data charting—key information was extracted from each study using a structured framework.

Stage 5: Collating, summarising, and reporting results—findings were analysed using qualitative thematic analysis and presented in Table 2.

Data Analysis

A preliminary research into internet sources resulted in a selection of articles to which qualitative thematic analysis was applied in order to identify key themes generating ideas for the research questions. The first or so-called identification phase started after the introduction of the defined filters. Given the vast amount of literature reviewed, a deductive content analysis method was applied to group different ideas into categories. The second phase was completed by examining the full-text version of the selected works and excluding those that did not fit the specific topic. An inductive content analysis approach was used in order to group key guidelines and recommendations for improving nursing education in Bulgaria. The following information was extracted for each study: database; authors/title/year/country; main results/highlights (Table 2).

3. Results

The included studies covered a broad geographical range across Europe, including Northern (e.g., Norway, Finland), Southern (e.g., Portugal, Spain, Italy), Eastern (e.g., Bulgaria, Albania), and multi-country comparative analyses. Most studies originated from European Union member states, with a smaller proportion addressing wider international or global perspectives. This distribution reflects both the diversity of educational systems and the varying levels of research activity across regions. The number of publications initially identified was 1492. Analysis by title was performed to drop duplicates (n=108) and irrelevant (n=633). Using a screening method, abstracts were reviewed , and then 530 were excluded. 37 studies were eligible (PubMed-13, Google Scholar-16, Scopus-8). Of these, 22 were excluded because of specific subject matter not meeting the research objective, and 4 were not retrieved despite the specified open access filter.

Included in the review were 11 publications (PubMed-4, Google Scholar-5, Scopus-2) processed through the virtual bibliographic manager Mendeley Reference Manager (Version 2.137.0, Elsevier Ltd. 2025). Review articles were predominant (54.5%), with a notable absence of large cohort studies relating to quantitative measurements of nursing education issues.

4. Discussion

The findings of the review were subjected to an analysis that outlined several main directions for improvement of the Bulgarian system against the background of current European practices.

4.1. Participation and Support of Pan-European Initiatives in Education

The Bologna Plan marks the beginning of the European Community’s aspirations to harmonise education by creating a single higher education area, aligning criteria and requirements across Member States. Two European alignment frameworks have been established—the ENEA and the EQF (European Qualifications Framework), the latter with similar objectives, namely to support the cross-border mobility of students and workers and to promote lifelong learning and professional development across Europe. The Bologna Process and the European Union Directive 2005/36/EC aim to harmonise minimum educational requirements to facilitate the free movement of professionals (and clients) across Europe [18]. A number of studies years after the launch of the process have attempted to look at the results achieved in a panoramic way, taking into account the similarities and still existing differences in the education systems of European countries. For example, Lahtinen et al. through a systematic review looked at nurse education in 45 ENEA member states, reporting quite a few similarities as early as 2014 [25]. One of them is that 60% of the countries offer a complete educational cycle for nurses with bachelor, master and doctoral programmes [25]. Similar results are presented in another systematic review providing a comparative analysis between 19 ENEA member countries. Significant criteria adopted by most countries are the integration of nursing education into university education and the fixation of its duration between 3 and 4 years [20]. Another review study by Portuguese and Romanian authors searched for differences and similarities in nursing curricula in 15 countries, considering the advantages of 4-year training and the 240 ECTS credit system for students’ future professional development [21]. The same author studied nursing education in southern European countries (Portugal, Spain, Italy and Greece) against the background of their national legal frameworks and reported similarities in curricula (240 ECTS) [17]. The need for European and even global standards is driven not only by the free movement of labour but also by the requirement for standard, measurable and quality health care. In 2020, declared the Year of the Non-Nurse and Midwife, educators from 3 continents with the support of WHO and the then World Nursing Status Report 2020 initiated the structuring of the so-called Global Pillars framework to create up-to-date guidelines in the field of nursing education harmonization [22]. In the latest WHO report of 2025, particular attention is given to the issue of nurse education. Encouragingly, the overall ratio of nursing graduates to the population in the European region shows the highest ratio (42.7 per 100,000) [27]. Another reported positive trend is the fact that among the member states that responded on regulation and standards for nursing education, 90% have policies for faculty qualifications, 88% use accreditation mechanisms for education and training institutions, and 77% participate in collaborative efforts between these institutions and regulatory bodies [27]. There have been studies that demonstrate a poor approach in attempting to standardise nursing qualifications, such as that of Eines et al. showing a lack of alignment between EU adopted qualification criteria and existing national qualification frameworks [23].

The unification of curricula and programmes has didactic as well as professional objectives, allowing international mobility for the purpose of learning during basic and postgraduate studies. Some of these programmes, such as Erasmus, are not only for nursing or higher education, but for several years there has been a European nursing module, which is aimed at students and provides the opportunity for a two-week exchange of experiences and impressions between different institutions and countries providing nursing training. A study by Lopez-Duarte (2021) identified the main barriers to European student mobility, namely: language barriers, student employment, mobility constraints and social segregation [28]. Despite this accountability, the success rate of ERASMUS in ENEA is high and annually allows lecturers, students and administrative staff related to higher education to travel to different countries, inside and outside the EU, which increases at least intercultural integration and language skills.

4.2. Unifying Clinical Competences and the Role of the Health System

Striving for alignment of training programs is an overture to a robust and unified competency of working nurses who are free to take up positions in their chosen institution and country. Clinical practice set as half of the total horary and each country clarifies its requirements for distribution of hours, locations, mode and time of delivery. For example, northern European countries that have significant similarities in social and health aspects rely on the implementation of the European framework through extended requirements for the medical profession and thus for education as the ability to plan, organize, evaluate and communicate the medical care provided [24]. Because of the expanding care in the community and the high number of chronically ill patients in need of nursing care at home, they reported the shortage of hours for such clinical practice compared to hospital practice and the possibility of simulation training in the absence of a real environment [24]. The knowledge and competencies acquired in clinical settings are measurable with standardized and validated scales, such as those for professional competence, on which many studies are based and which allow for the unification of nurses’ abilities to work in clinical settings. Again, most such studies come from Scandinavian countries, which unfortunately cannot be extrapolated to the rest of Europe. Nilsson et al. surveyed over 700 nursing students in 11 European higher education institutions on a professional competence scale covering 88 items from 8 competence domains [19]. Central European countries showed higher self-reported competence, with nurses feeling most competent in values-based care [19]. Another study from Eastern Europe presents evidence that it is moral values that are most important for the formation of professional qualities in trainee nurses [31].When competencies are considered at the international level, domains are added, modified or removed, depending on the national characteristics of the higher education and health care system. In a later international study, the competencies were divided into ten different domains: (1) Professional Attitude, (2) Clinical Care in Practice, (3) Communication and Collaboration, (4) Health Promotion and Prevention, (5) Care Organization and Planning, (6) Leadership, (7) Quality and Safety of Care, (8) Training and (Continuing) Education, (9) Technology and eHealth, (10) Self-Management Support and Patient Empowerment [29]. The classification and assessment of competences in different domains aims to achieve one of the secondary objectives of the Bologna Process, namely to assess, monitor and improve the quality of training. In addition to the educational trajectory, the level of the health system and existing health policies play a significant role in the development of professional competences. They provide the material and technical base, the legal framework, the financial backing and other relevant aspects for building nursing competence. Part of this material provision is devoted to resources related to eHealth and the digitisation of most hospital processes. Nurses are some of the first professionals confronted with these changes because of their administrative functions. In addition to hospital-wide software, many countries have what is known as digitization of the nursing process, which is of great importance for tracking care and its quality. In the case of electronic documentation, nursing care should be an integral and mandatory part of it, serving to identify the role and place of the nurse in the process of patient care [30]. Creating the conditions for an electronic nursing record requires the involvement of a number of institutions and the nursing contingent itself, something that has yet to happen in Bulgaria.

4.3. Evidence-Based Teaching and the Role of Higher Education Institutions

With the beginning of the new millennium, the terminology of ‘evidence-based practice’ was introduced to describe the scientifically based, evidenced and validated actions and methods that are applied in various fields of human knowledge. Evidence-based nursing is a motto under which to develop scientific thinking and research. Pedagogical activity falls under the same criteria and is a prerequisite to this nursing through nursing teaching, also evidence-based. A descriptive study following a collaboration of six European countries explored what proportion of curricula possess evidence-based teaching concepts that may have different focuses: developing research knowledge, awareness of the need for evidence-based clinical work, and understanding the needs of the profession [31]. At this stage, there is an absence of this type of teaching in most participating countries and a complete lack of data from other ENEA members. Such a teaching model breaks existing stereotypes and requires students to build dynamic reasoning in search of patterns rather than one-way assimilation of information. This is where one of the most serious differences between countries with established traditions in nursing education and practice and other European countries has its roots- programs to stimulate autonomous thinking and adequate clinical decision making. Evidence-based teaching is also a prerequisite for increasing nurses’ interest in research. Universities make a significant contribution to guiding students in the direction of researchers and are organizationally and materially responsible for the development of this area of nursing science. As the professions of health care professionals are practice-oriented, research activities are absolutely necessary for them to develop clinical practice and quality outcomes [32]. Dervishi et al. compared Albanian education with international standards and one of the main conclusions is that education plays a fundamental role not only in the technical training of nurses, but also in the promotion of ethical, relational and professional values that are essential for clinical work [26]. Lack of educational resources and demands on educators further complicates these processes. The role of universities and medical colleges and schools as the primary precursor to quality nursing is undeniable, although at times the traditions of these institutions may be a hindrance rather than a prerequisite for success.

5. Conclusions

We may be decades away from achieving maximum consistency between nurse training curricula in Europe and yet the path Bulgaria has travelled in the last 20 years shows opportunities for even better results. The European community’s drive for joined-up qualifications, competences and training is a drive to guarantee quality healthcare in the long term against the backdrop of an increasingly diluted profession. More research is needed to show the methods needed to correct the differences in the theoretical and practical aspects of the training process. At this stage, adherence to the standards of countries with more experience in nurse training is perceived as a winning behaviour. Participation in international and European initiatives such as exchange programmes and international mobility contributes to the development of ideas and useful practices on national territory. In addition, strong government policies at university level and above are needed to improve current plans. The role of the health system as the main consumer of health care professionals should be more investing than consuming. Regarding education itself, there is a need to introduce an evidence-based teaching methodology and promote research-based thinking and action in nursing science and practice. The latter is interconnected with the maintenance and development of a robust postgraduate and continuing education that motivates students and practitioners. Last but not least, a reliable system for monitoring and evaluating the quality of the above processes is needed to serve as a feedback loop in the design and development of future policies in this area.